Experts say that malnutrition, heat, humidity, and poor hygiene are key reasons for the outbreak of Acute Encephalitis Syndrome (AES). All these factors are present in Muzaffarpur and surrounding areas of Bihar. Meanwhile, Union Health Minister Harsh Vardhan arrived in the state capital on Sunday to review public health measures for containment and management of the AES. According to fresh reports, three more children succumbed to Acute Encephalitis Syndrome in Muzaffarpur. The death toll number rose above 80 on Sunday in the district. Bihar Chief Minister Nitish Kumar announced an ex gratia of Rs 4 lakh each to families of the children who died due to AES in Muzaffarpur.
Bihar Health Minister Mangal Pandey said that a team that was formed to ascertain the cause of this disease concluded that sleeping empty stomach at night, dehydration due to humidity and eating lychee on empty stomach were some of the causes of Encephalitis. He said, “Our government has tried to spread awareness which will be beneficial as well. Advertisement in newspapers, radio jingles, pamphlets and mike announcements are going to spread awareness regarding the disease. Health ministry is also working on it.” Doctors claim that the deaths are being caused due to excessive heat and humidity.
What is Acute Encephalitis Syndrome?
Acute Encephalitis Syndrome (AES) including Japanese Encephalitis (JE) is a group of clinically similar neurologic manifestation caused by several different viruses, bacteria, fungus, parasites, spirochetes, chemical/ toxins, etc. The outbreak of JE usually coincides with the monsoon and post-monsoon period when the density of mosquitoes increases while encephalitis due to other viruses specially entero-viruses occurs throughout the year as it is a water-borne disease. AES affects the central nervous system, mostly in children and young adults. It starts with high fever, then hampers neurological functions causing mental disorientation, seizure, confusion, delirium, coma.
Japanese encephalitis (JE) virus is the most common cause of AES in India, with union health ministry estimate attributing 5-35 per cent cases due to JE. But the syndrome is also caused by scrub typhus, dengue, mumps, measles, even Nipah or Zika virus. In several cases, the cause of AES remains clinically unidentified.
Who is affected?
It predominantly affects the population below 15 years. There is seasonal and geographical variation in the causative organism. JEV has its endemic zones running along the Gangetic plane including states of UP (East), Bihar, West Bengal, and Assam, and parts of Tamil Nadu. In India, AES outbreaks in the north and eastern India have been linked to children eating unripe litchi fruit on empty stomachs. Unripe fruit contains the toxins hypoglycin A and methylenecyclopropylglycine (MCPG), which cause vomiting if ingested in large quantities. Hypoglycin A is a naturally occurring amino acid found in the unripened litchi that causes severe vomiting (Jamaican vomiting sickness), while MCPG is a poisonous compound found in litchi seeds that causes a sudden drop in blood sugar, vomiting, altered mental states leading to lethargy, unconsciousness, coma, and death. These toxins cause sudden high fever and seizures serious enough to require hospitalisation in young, severely malnourished children.
Signs and Symptoms of the disease
Acute encephalitis syndrome (AES) is characterized by an acute onset of fever and clinical neurological manifestation that includes mental confusion, disorientation, delirium, or coma. Apart from viral encephalitis, a severe form of leptospirosis and toxoplasmosis can cause AES. Keeping in mind the wide range of causal agents and the rapid rate of neurological impairment due to pathogenesis, clinicians face the challenge of a small window period between diagnosis and treatment. Several government initiatives have been undertaken to educate and improve the hygiene of people living in the JE endemic zones. Government and non-government organizations have been instrumental in providing proper nutrition to the AES-affected population as most of the affected people belong to the lower economic strata of society.
The relation between hypoglycaemia, children, and AES
Bihar government officials claim AES is a syndrome not a disease, and cause of death in children was found to be prolonged hypoglycaemia that witnessed the delayed treatment. In 2014 research paper titled ‘Epidemiology of Acute Encephalitis Syndrome in India: Changing Paradigm and Implication for Control’, co-authored by six researchers, a parallel was drawn between Muzaffarpur and Vietnam’s Bac Giang province where undernourished children were suffering from AES and hypoglycaemia that coincided with litchi orchards in the neighbourhood. “The possible association with some toxin in litchi or in the environment needs to be documented. Methylene cyclopropyl glycine (MCPG) which has been known to be a content of litchi fruit has been shown to cause hypoglycaemia in experimental animals,” the study stated. Several children in Muzaffarpur who suffer from AES before 2014 have a history of the visit to litchi orchards, the study found. The impact is worse on undernourished children who remain hungry for several hours.
Affected states and areas in India
According to the National Vector Borne Diseases Control Programme (NVBDCP), 10,485 AES cases were diagnosed in 2018 with 632 deaths across 17 states. India records fatality rate at 6 per cent in AES, but the fatality rises to 25 per cent amongst children. Bihar, Assam, Jharkhand, Uttar Pradesh, Manipur, Meghalaya, Tamil Nadu, Karnataka, and Tripura are the worst affected.
No doctors on call during the night
Meanwhile, on Sunday attendants of patients admitted to the SKMCH alleged that there were no doctors on call during the night. Mohammad Aftab told ANI, “My daughter is in the ICU room of SKMCH. The death toll is increasing day by day. There were no doctors after 12 in the night and only nurses are here. There are four bodies inside ICU.” Another attendant, Sunil Ram said, “My four-year-old daughter was admitted to hospital on Saturday. She was declared dead today. There is no facility in SKMCH.”
Black flags displayed
Union Health Minister Harsh Vardhan arrived in the state capital today to review public health measures for containment and management of the AES. Vardhan had previously said that the Centre was constantly monitoring the situation and supporting state health authorities to manage the encephalitis cases. The minister was greeted here with black flags displayed by workers of the Jan Adhikar Party Loktantrik (LJP) who shouted slogans against him.